Blue Cross and Blue Shield Service Benefit Plan

Transcription

1 Blue Cross and Blue Shield Service Benefit Plan A fee-for-service plan (standard and basic option) with a preferred provider organization IMPORTANT: Rates: Back Cover Changes for 2015: Page 15 Summary of benefits: Page 157 This Plan s health coverage qualifies as minimum essential coverage and meets the minimum value standard for the benefits it provides. See page 9 for details. Sponsored and administered by: The Blue Cross and Blue Shield Association and participating Blue Cross and Blue Shield Plans Who may enroll in this Plan: All Federal employees, Tribal employees, and annuitants who are eligible to enroll in the Federal Employees Health Benefits Program Enrollment codes for this Plan: 104 Standard Option - Self Only 105 Standard Option - Self and Family 111 Basic Option - Self Only 112 Basic Option - Self and Family The Case Management programs for this Plan are accredited through URAC or NCQA, or through Health Plan accreditation from NCQA. See the 2015 FEHB Guide for more information on accreditation. Authorized for distribution by the: RI

2 Important Notice from the Blue Cross and Blue Shield Service Benefit Plan About Our Prescription Drug Coverage and Medicare OPM has determined that the Blue Cross and Blue Shield Service Benefit Plan s prescription drug coverage is, on average, expected to pay out as much as the standard Medicare prescription drug coverage will pay for all plan participants and is considered Creditable Coverage. This means you do not need to enroll in Medicare Part D and pay extra for prescription drug coverage. If you decide to enroll in Medicare Part D later, you will not have to pay a penalty for late enrollment as long as you keep your FEHB coverage. However, if you choose to enroll in Medicare Part D, you can keep your FEHB coverage and your FEHB plan will coordinate benefits with Medicare. Remember: If you are an annuitant and you cancel your FEHB coverage, you may not re-enroll in the FEHB Program. Please be advised If you lose or drop your FEHB coverage and go 63 days or longer without prescription drug coverage that s at least as good as Medicare s prescription drug coverage, your monthly Medicare Part D premium will go up at least 1% per month for every month that you did not have that coverage. For example, if you go 19 months without Medicare Part D prescription drug coverage, your premium will always be at least 19 percent higher than what many other people pay. You will have to pay this higher premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the next Annual Coordinated Election Period (October 15 through December 7) to enroll in Medicare Part D. Medicare s Low Income Benefits For people with limited income and resources, extra help paying for a Medicare prescription drug plan is available. Information regarding this program is available through the Social Security Administration (SSA) online at or call the SSA at (TTY: ). You can get more information about Medicare prescription drug plans and the coverage offered in your area from these places: Visit for personalized help. Call MEDICARE ( ), (TTY: ). 2

3 Table of Contents Introduction... 5 Plain Language... 5 Stop Health Care Fraud!... 5 Preventing Medical Mistakes... 6 FEHB Facts... 9 Coverage information... 9 No pre-existing condition limitation... 9 Minimum essential coverage (MEC)... 9 Minimum value standard... 9 Where you can get information about enrolling in the FEHB Program... 9 Types of coverage available for you and your family... 9 Family member coverage Children s Equity Act When benefits and premiums start When you retire When you lose benefits When FEHB coverage ends Upon divorce Temporary Continuation of Coverage (TCC) Finding replacement coverage Health Insurance Marketplace Section 1. How this Plan works General features of our Standard and Basic Options We have a Preferred Provider Organization (PPO) How we pay professional and facility providers Your rights Your medical and claims records are confidential Section 2. Changes for Section 3. How you receive benefits Identification cards Where you get covered care Covered professional providers Covered facility providers What you must do to get covered care Transitional care If you are hospitalized when your enrollment begins You need prior Plan approval for certain services Inpatient hospital admission Other services How to request precertification for an admission or get prior approval for Other services Non-urgent care claims Urgent care claims Concurrent care claims Emergency inpatient admission Maternity care If your hospital stay needs to be extended If your treatment needs to be extended If you disagree with our pre-service claim decision To reconsider a non-urgent care claim To reconsider an urgent care claim To file an appeal with OPM Service Benefit Plan 3 Table of Contents

4 Section 4. Your costs for covered services Cost-sharing Copayment Deductible Coinsurance If your provider routinely waives your cost Waivers Differences between our allowance and the bill Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, and copayments Carryover If we overpay you When Government facilities bill us Section 5. Benefits Standard and Basic Option Benefits Non-FEHB benefits available to Plan members Section 6. General exclusions services, drugs, and supplies we do not cover Section 7. Filing a claim for covered services Section 8. The disputed claims process Section 9. Coordinating benefits with Medicare and other coverage When you have other health coverage TRICARE and CHAMPVA Workers Compensation Medicaid When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) Clinical trials When you have Medicare What is Medicare? Should I enroll in Medicare? The Original Medicare Plan (Part A or Part B) Tell us about your Medicare coverage Private contract with your physician Medicare Advantage (Part C) Medicare prescription drug coverage (Part D) Medicare prescription drug coverage (Part B) When you are age 65 or over and do not have Medicare When you have the Original Medicare Plan (Part A, Part B, or both) Section 10. Definitions of terms we use in this brochure Section 11. Other Federal Programs The Federal Flexible Spending Account Program FSAFEDS The Federal Employees Dental and Vision Insurance Program FEDVIP The Federal Long Term Care Insurance Program FLTCIP Index Summary of benefits for the Blue Cross and Blue Shield Service Benefit Plan Standard Option Summary of benefits for the Blue Cross and Blue Shield Service Benefit Plan Basic Option Rate Information for the Blue Cross and Blue Shield Service Benefit Plan Service Benefit Plan 4 Table of Contents

5 Introduction This brochure describes the benefits of the Blue Cross and Blue Shield Service Benefit Plan under our contract (CS 1039) with the United States Office of Personnel Management, as authorized by the Federal Employees Health Benefits law. This Plan is underwritten by participating Blue Cross and Blue Shield Plans (Local Plans) that administer this Plan in their individual localities. For customer service assistance, visit our website, or contact your Local Plan at the telephone number appearing on the back of your ID card. The Blue Cross and Blue Shield Association is the Carrier of the Plan. The address for the Blue Cross and Blue Shield Service Benefit Plan administrative office is: Blue Cross and Blue Shield Service Benefit Plan 1310 G Street, NW, Suite 900 Washington, DC This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your health care benefits. If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were available before January 1, 2015, unless those benefits are also shown in this brochure. OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2015, and changes are summarized on pages Rates are shown on the back cover of this brochure. Coverage under this Plan qualifies as minimum essential coverage (MEC) and satisfies the Patient Protection and Affordable Care Act s (ACA) individual shared responsibility requirement. Please visit the Internal Revenue Service (IRS) website at for more information on the individual requirement for MEC. The ACA establishes a minimum value for the standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). The health coverage of this Plan meets the minimum value standard for the benefits the Plan provides. Plain Language All FEHB brochures are written in plain language to make them easy to understand. Here are some examples: Except for necessary technical terms, we use common words. For instance, you means the enrollee or family member; we means the Blue Cross and Blue Shield Service Benefit Plan. We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the United States Office of Personnel Management. If we use others, we tell you what they mean. Our brochure and other FEHB plans brochures have the same format and similar descriptions to help you compare plans. Stop Health Care Fraud! Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits Program premium. OPM s Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the agency that employs you or from which you retired. Protect Yourself From Fraud Here are some things you can do to prevent fraud: Do not give your plan identification (ID) number over the telephone or to people you do not know, except for your health care provider, authorized health benefits plan, or OPM representative. Let only the appropriate medical professionals review your medical record or recommend services. Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it paid. Carefully review explanations of benefits (EOBs) statements that you receive from us. Periodically review your claim history for accuracy to ensure we have not been billed for services that you did not receive. Service Benefit Plan 5 Introduction/Plain Language/Advisory

6 Do not ask your doctor to make false entries on certificates, bills, or records in order to get us to pay for an item or service. If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following: Call the provider and ask for an explanation. There may be an error. If the provider does not resolve the matter, call the FEP Fraud Hotline at FEP-8440 ( ) and explain the situation. If we do not resolve the issue: CALL THE HEALTH CARE FRAUD HOTLINE OR go to You can also write to: United States Office of Personnel Management Office of the Inspector General Fraud Hotline 1900 E Street NW Room 6400 Washington, DC Do not maintain as a family member on your policy: Your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or Your child age 26 or over (unless he/she was disabled and incapable of self-support prior to age 26). If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed, with your retirement office (such as OPM) if you are retired, or with the National Finance Center if you are enrolled under Temporary Continuation of Coverage. Fraud or intentional misrepresentation of material fact is prohibited under the Plan. You can be prosecuted for fraud and your agency may take action against you. Examples of fraud include falsifying a claim to obtain FEHB benefits, trying to or obtaining service or coverage for yourself or for someone who is not eligible for coverage, or enrolling in the Plan when you are no longer eligible. If your enrollment continues after you are no longer eligible for coverage (i.e., you have separated from Federal service) and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid. You may be billed by your provider for services received. You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums. It is your responsibility to know when you or a family member is no longer eligible to use your health insurance coverage. Preventing Medical Mistakes An influential report from the Institute of Medicine estimates that up to 98,000 Americans die every year from medical mistakes in hospitals alone. That s about 3,230 preventable deaths in the FEHB Program a year. While death is the most tragic outcome, medical mistakes cause other problems such as permanent disabilities, extended hospital stays, longer recoveries, and even additional treatments. By asking questions, learning more and understanding your risks, you can improve the safety of your own health care, and that of your family members. Take these simple steps: 1. Ask questions if you have doubts or concerns. Ask questions and make sure you understand the answers. Choose a doctor with whom you feel comfortable talking. Take a relative or friend with you to help you ask questions and understand answers. Service Benefit Plan 6 Introduction/Plain Language/Advisory

7 2. Keep and bring a list of all the medicines you take. Bring the actual medicines or give your doctor and pharmacist a list of all the medicines and dosage that you take, including non-prescription (over-the-counter) medicines and nutritional supplements. Tell your doctor and pharmacist about any drug, food, and other allergies you have, such as to latex. Ask about any risks or side effects of the medication and what to avoid while taking it. Be sure to write down what your doctor or pharmacist says. Make sure your medicine is what the doctor ordered. Ask the pharmacist about your medicine if it looks different than you expected. Read the label and patient package insert when you get your medicine, including all warnings and instructions. Know how to use your medicine. Especially note the times and conditions when your medicine should and should not be taken. Contact your doctor or pharmacist if you have any questions. 3. Get the results of any test or procedure. Ask when and how you will get the results of tests or procedures. Do not assume the results are fine if you do not get them when expected, be it in person, by phone, or by mail. Call your doctor and ask for your results. Ask what the results mean for your care. 4. Talk to your doctor about which hospital is best for your health needs. Ask your doctor about which hospital has the best care and results for your condition if you have more than one hospital to choose from to get the health care you need. Be sure you understand the instructions you get about follow-up care when you leave the hospital. 5. Make sure you understand what will happen if you need surgery. Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation. Ask your doctor, Who will manage my care when I am in the hospital? Ask your surgeon: Exactly what will you be doing? About how long will it take? What will happen after surgery? How can I expect to feel during recovery? Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reactions to anesthesia, and any medications or nutritional supplements you are taking. Patient Safety Links The Agency for Healthcare Research and Quality makes available a wide-ranging list of topics not only to inform consumers about patient safety but to help choose quality health care providers and improve the quality of care you receive. The National Patient Safety Foundation has information on how to ensure safer health care for you and your family. The National Council on Patient Information and Education is dedicated to improving communication about the safe, appropriate use of medicines. The Leapfrog Group is active in promoting safe practices in hospital care. The American Health Quality Association represents organizations and health care professionals working to improve patient safety. Service Benefit Plan 7 Introduction/Plain Language/Advisory

8 Never Events When you enter the hospital for treatment of one medical problem, you don t expect to leave with additional injuries, infections, or other serious conditions that occur during the course of your stay. Although some of these complications may not be avoidable, too often patients suffer from injuries or illnesses that could have been prevented if the hospital had taken proper precautions. We have a benefit payment policy that encourages hospitals to reduce the likelihood of hospital-acquired conditions such as certain infections, severe bedsores, and fractures, and to reduce medical errors that should never happen. These conditions and errors are called Never Events. When a Never Event occurs, neither your FEHB plan nor you will incur costs to correct the medical error. You will not be billed for inpatient services related to treatment of specific hospital-acquired conditions or for inpatient services needed to correct Never Events, if you use Service Benefit Plan Preferred or Member hospitals. This policy helps to protect you from preventable medical errors and improve the quality of care you receive. Service Benefit Plan 8 Introduction/Plain Language/Advisory

9 FEHB Facts Coverage information No pre-existing condition limitation Minimum essential coverage (MEC) Minimum value standard Where you can get information about enrolling in the FEHB Program Types of coverage available for you and your family We will not refuse to cover the treatment of a condition you had before you enrolled in this Plan solely because you had the condition before you enrolled. Coverage under this Plan qualifies as minimum essential coverage (MEC) and satisfies the Patient Protection and Affordable Care Act s (ACA) individual shared responsibility requirement. Please visit the Internal Revenue Service (IRS) website at for more information on the individual requirement for MEC. Our health coverage meets the minimum value standard of 60% established by the ACA. This means that we provide benefits to cover at least 60% of the total allowed costs of essential health benefits. The 60% standard is an actuarial value; your specific out-of-pocket costs are determined as explained in this brochure. See for enrollment information as well as: Information on the FEHB Program and plans available to you A health plan comparison tool A list of agencies that participate in Employee Express A link to Employee Express Information on and links to other electronic enrollment systems Also, your employing or retirement office can answer your questions, and give you a Guide to Federal Benefits, brochures for other plans, and other materials you need to make an informed decision about your FEHB coverage. These materials tell you: When you may change your enrollment How you can cover your family members What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire What happens when your enrollment ends When the next Open Season for enrollment begins We do not determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your employing or retirement office. For information on your premium deductions, you must also contact your employing or retirement office. Self Only coverage is for you alone. Self and Family coverage is for you, your spouse, and your dependent children under age 26, including any foster children authorized for coverage by your employing agency or retirement office. Under certain circumstances, you may also continue coverage for a disabled child 26 years of age or older who is incapable of self-support. If you have a Self Only enrollment, you may change to a Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your enrollment 31 days before to 60 days after that event. The Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family member. When you change to Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment form; benefits will not be available to your spouse until you marry. Your employing or retirement office will not notify you when a family member is no longer eligible to receive health benefits, nor will we. Please tell us immediately of changes in family member status, including your marriage, divorce, annulment, or when your child reaches age 26. If you or one of your family members is enrolled in one FEHB plan, that person may not be enrolled in or covered as a family member by another FEHB plan. Service Benefit Plan 9 FEHB Facts

10 Family member coverage If you have a qualifying life event (QLE) such as marriage, divorce, or the birth of a child outside of the Federal Benefits Open Season, you may be eligible to enroll in the FEHB Program, change your enrollment, or cancel coverage. For a complete list of QLEs, visit the FEHB website at If you need assistance, please contact your employing agency, Tribal Benefits Officer, personnel/payroll office, or retirement office. Family members covered under your Self and Family enrollment are your spouse (including your spouse by valid common-law marriage if you reside in a state that recognizes common-law marriages) and children as described in the chart below. Children Natural children, adopted children, and stepchildren Foster children Children incapable of selfsupport Married children Children with or eligible for employer-provided health insurance Coverage Natural children, adopted children, and stepchildren (including children of same-sex domestic partners in certain states) are covered until their 26th birthday. Foster children are eligible for coverage until their 26th birthday if you provide documentation of your regular and substantial support of the child and sign a certification stating that your foster child meets all the requirements. Contact your human resources office or retirement system for additional information. Children who are incapable of self-support because of a mental or physical disability that began before age 26 are eligible to continue coverage. Contact your human resources office or retirement system for additional information. Married children (but NOT their spouse or their own children) are covered until their 26th birthday. Children who are eligible for or have their own employer-provided health insurance are covered until their 26th birthday. You can find additional information at Children s Equity Act OPM has implemented the Federal Employees Health Benefits Children s Equity Act of This law mandates that you be enrolled for Self and Family coverage in the FEHB Program, if you are an employee subject to a court or administrative order requiring you to provide health benefits for your child(ren). If this law applies to you, you must enroll for Self and Family coverage in a health plan that provides full benefits in the area where your children live or provide documentation to your employing office that you have obtained other health benefits coverage for your children. If you do not do so, your employing office will enroll you involuntarily as follows: If you have no FEHB coverage, your employing office will enroll you for Self and Family coverage in the Blue Cross and Blue Shield Service Benefit Plan s Basic Option; If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your enrollment to Self and Family in the same option of the same plan; or If you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self and Family in the Blue Cross and Blue Shield Service Benefit Plan s Basic Option. Service Benefit Plan 10 FEHB Facts

11 When benefits and premiums start When you retire When you lose benefits When FEHB coverage ends Upon divorce As long as the court/administrative order is in effect, and you have at least one child identified in the order who is still eligible under the FEHB Program, you cannot cancel your enrollment, change to Self Only, or change to a plan that doesn t serve the area in which your children live, unless you provide documentation that you have other coverage for the children. If the court/administrative order is still in effect when you retire, and you have at least one child still eligible for FEHB coverage, you must continue your FEHB coverage into retirement (if eligible) and cannot cancel your coverage, change to Self Only, or change to a plan that doesn t serve the area in which your children live as long as the court/administrative order is in effect. Contact your employing office for further information. The benefits in this brochure are effective on January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be paid according to the 2015 benefits of your old plan or option. However, if your old plan left the FEHB Program at the end of the year, you are covered under that plan s 2014 benefits until the effective date of your coverage with your new plan. Annuitants coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage. If your enrollment continues after you are no longer eligible for coverage (i.e., you have separated from Federal service), and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid. You may be billed for services received directly from your provider. You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums. It is your responsibility to know when you or a family member are no longer eligible to use your health insurance coverage. When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years of your Federal service. If you do not meet this requirement, you may be eligible for other forms of coverage, such as Temporary Continuation of Coverage (TCC). You will receive an additional 31 days of coverage, for no additional premium, when: Your enrollment ends, unless you cancel your enrollment; or You are a family member no longer eligible for coverage. Any person covered under the 31-day extension of coverage who is confined in a hospital or other institution for care or treatment on the 31st day of the temporary extension is entitled to continuation of the benefits of the Plan during the continuance of the confinement but not beyond the 60th day after the end of the 31-day temporary extension. You may be eligible for spouse equity coverage or Temporary Continuation of Coverage (TCC). If you are divorced from a Federal employee or annuitant you may not continue to get benefits under your former spouse s enrollment. This is the case even when the court has ordered your former spouse to provide health benefits coverage for you. However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse s employing or retirement office to get RI 70-5, the Guide to Federal Benefits for Temporary Continuation of Coverage and Former Spouse Enrollees, or other information about your coverage choices. You can also download the guide from OPM s website, Service Benefit Plan 11 FEHB Facts

12 Temporary Continuation of Coverage (TCC) Finding replacement coverage Health Insurance Marketplace If you leave Federal service, Tribal employment, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). The Affordable Care Act (ACA) did not eliminate TCC or change the TCC rules. For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your Federal job, if you are a covered dependent child and you turn age 26, regardless of marital status, etc. You may not elect TCC if you are fired from your Federal or Tribal job due to gross misconduct. Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide to Federal Benefits for Temporary Continuation of Coverage and Former Spouse Enrollees, from your employing or retirement office or from It explains what you have to do to enroll. Alternatively, you can buy coverage through the Health Insurance Marketplace where, depending on your income, you could be eligible for a new kind of tax credit that lowers your monthly premiums. Visit to compare plans and see what your premium, deductible, and out-of-pocket costs would be before you make a decision to enroll. Finally, if you qualify for coverage under another group health plan (such as your spouse s plan), you may be able to enroll in that plan, as long as you apply within 30 days of losing FEHBP coverage. This Plan no longer offers its own non-fehb plan for conversion purposes. If you would like to purchase health insurance through the Affordable Care Act s Health Insurance Marketplace, please refer to the next section of this brochure. Although we no longer offer conversion coverage, we will help you find replacement coverage inside or outside the Marketplace. For assistance, please contact your Local Plan at the telephone number appearing on the back of your ID card, or visit to access the website of your Local Plan. Note: We do not determine who is eligible to purchase health benefits coverage inside the Affordable Care Act s Health Insurance Marketplace. These rules are established by the Federal Government agencies that have responsibility for implementing the Affordable Care Act and by the Marketplace. If you would like to purchase health insurance through the Affordable Care Act s Health Insurance Marketplace, please visit This is a website provided by the U.S. Department of Health and Human Services that provides up-to-date information on the Marketplace. Service Benefit Plan 12 FEHB Facts

13 Section 1. How this Plan works This Plan is a fee-for-service (FFS) plan. You can choose your own physicians, hospitals, and other health care providers. We reimburse you or your provider for your covered services, usually based on a percentage of the amount we allow. The type and extent of covered services, and the amount we allow, may be different from other plans. Read brochures carefully. General features of our Standard and Basic Options We have a Preferred Provider Organization (PPO) Our fee-for-service plan offers services through a PPO. This means that certain hospitals and other health care providers are Preferred providers. When you use our PPO (Preferred) providers, you will receive covered services at a reduced cost. Your Local Plan (or, for retail pharmacies, CVS Caremark) is solely responsible for the selection of PPO providers in your area. Contact your Local Plan for the names of PPO (Preferred) providers and to verify their continued participation. You can also go to our website, and select Provider Directory to use our National Doctor & Hospital Finder SM. You can reach our website through the FEHB website, Under Standard Option, PPO (Preferred) benefits apply only when you use a PPO (Preferred) provider. PPO networks may be more extensive in some areas than in others. We cannot guarantee the availability of every specialty in all areas. If no PPO (Preferred) provider is available, or you do not use a PPO (Preferred) provider, non-ppo (Non-preferred) benefits apply. Under Basic Option, you must use Preferred providers in order to receive benefits. See page 20 for the exceptions to this requirement. Note: Dentists and oral surgeons who are in our Preferred Dental Network for routine dental care are not necessarily Preferred providers for other services covered by this Plan under other benefit provisions (such as the surgical benefit for oral and maxillofacial surgery). Call us at the customer service number on the back of your ID card to verify that your provider is Preferred for the type of care (e.g., routine dental care or oral surgery) you are scheduled to receive. How we pay professional and facility providers We pay benefits when we receive a claim for covered services. Each Local Plan contracts with hospitals and other health care facilities, physicians, and other health care professionals in its service area, and is responsible for processing and paying claims for services you receive within that area. Many, but not all, of these contracted providers are in our PPO (Preferred) network. PPO providers. PPO (Preferred) providers have agreed to accept a specific negotiated amount as payment in full for covered services provided to you. We refer to PPO facility and professional providers as Preferred. They will generally bill the Local Plan directly, who will then pay them directly. You do not file a claim. Your out-of-pocket costs are generally less when you receive covered services from Preferred providers, and are limited to your coinsurance or copayments (and, under Standard Option only, the applicable deductible). Participating providers. Some Local Plans also contract with other providers that are not in our Preferred network. If they are professionals, we refer to them as Participating providers. If they are facilities, we refer to them as Member facilities. They have agreed to accept a different negotiated amount than our Preferred providers as payment in full. They will also generally file your claims for you. They have agreed not to bill you for more than your applicable deductible, and coinsurance or copayments, for covered services. We pay them directly, but at our Non-preferred benefit levels. Your out-of-pocket costs will be greater than if you use Preferred providers. Note: Not all areas have Participating providers and/or Member facilities. To verify the status of a provider, please contact the Local Plan where the services will be performed. Service Benefit Plan 13 Section 1

14 Non-participating providers. Providers who are not Preferred or Participating providers do not have contracts with us, and may or may not accept our allowance. We refer to them as Non-participating providers generally, although if they are facilities we refer to them as Non-member facilities. When you use Non-participating providers, you may have to file your claims with us. We will then pay our benefits to you, and you must pay the provider. You must pay any difference between the amount Non-participating providers charge and our allowance (except in certain circumstances see pages ). In addition, you must pay any applicable coinsurance amounts, copayment amounts, amounts applied to your calendar year deductible, and amounts for noncovered services. Important: Under Standard Option, your out-of-pocket costs may be substantially higher when you use Non-participating providers than when you use Preferred or Participating providers. Under Basic Option, you must use Preferred providers to receive benefits. See page 20 for the exceptions to this requirement. Note: In Local Plan areas, Preferred providers and Participating providers who contract with us will accept 100% of the Plan allowance as payment in full for covered services. As a result, you are only responsible for applicable coinsurance or copayments (and, under Standard Option only, the applicable deductible), for covered services, and any charges for noncovered services. Your rights OPM requires that all FEHB plans provide certain information to their FEHB members. You may get information about us, our networks, and our providers. OPM s FEHB website ( lists the specific types of information that we must make available to you. Some of the required information is listed below. Care management, including medical practice guidelines; Disease management programs; and How we determine if procedures are experimental or investigational. If you want more information about us, call or write to us. Our telephone number and address are shown on the back of your Service Benefit Plan ID card. You may also visit our website at Your medical and claims records are confidential We will keep your medical and claims information confidential. Note: As part of our administration of this contract, we may disclose your medical and claims information (including your prescription drug utilization) to any treating physicians or dispensing pharmacies. You may view our Notice of Privacy Practice for more information about how we may use and disclose member information by visiting our website at Service Benefit Plan 14 Section 1

15 Section 2. Changes for 2015 Do not rely only on these change descriptions; this Section is not an official statement of benefits. For that, go to Section 5 (Benefits). Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not change benefits. Changes to our Standard Option only Your share of the non-postal premium will increase for Self Only or increase for Self and Family. (See page 160.) Your copayment for care related to a medical emergency provided at a Preferred urgent care center is now $30 per visit. Previously, your copayment was $40 per visit. (See page 94.) Your cost-share for an inpatient admission to a Non-member hospital or other covered facility for mental health and substance abuse services is now 35% of the Plan allowance, and any remaining balance after our payment. Previously, you were also responsible for a $350 per admission copayment for these services. (See page 98.) Your cost-share for inpatient professional mental health and substance abuse services is now 35% of the Plan allowance for Participating and Non-participating providers. For services performed by Non-participating providers, you are also responsible for the difference between our allowance and the billed amount. Previously, you were also required to meet your calendar year deductible for these services. (See page 97.) We now provide benefits for inpatient admissions to residential treatment centers for mental health and substance abuse services for members who have primary Medicare Part A coverage. Previously, there were no benefits for this type of inpatient admission. (See page 98.) Changes to our Basic Option only Your share of the non-postal premium will increase for Self Only or increase for Self and Family. (See page 160.) Your cost-share for cardiovascular monitoring services is now $40 for services performed by Preferred professional or facility providers. You continue to have no copayment for standard EKGs. Previously, benefits for cardiovascular monitoring services performed by Preferred providers were not subject to a copayment. (See pages 38 and 82.) Your copayment for care related to an accidental injury or medical emergency provided at a Preferred urgent care center is now $35 per visit. Previously, your copayment was $50 per visit. (See pages 93 and 94.) Changes to both our Standard and Basic Options We now provide Preventive care benefits for genetic counseling and evaluation services and for preventive BRCA testing for males, age 18 and over, whose family history is associated with an increased risk for harmful mutations in BRCA1 or BRCA2 genes. Benefits are limited to one BRCA test per lifetime. Previously, Preventive care benefits for these services were not available for male members. (See page 41.) We now provide Preventive care benefits for BRCA testing in males and females with a family history of both breast and fallopian tube cancer or breast and primary peritoneal cancer among first- and second-degree relatives. Previously, the family history criteria for BRCA testing did not include the presence of fallopian tube or primary peritoneal cancer with breast cancer. (See page 41.) You must obtain prior approval for BRCA testing, whether it is performed for preventive or diagnostic reasons, before you receive the test. For preventive BRCA testing, you must also receive genetic counseling and evaluation services before the test is performed. Previously, BRCA testing was not subject to these requirements. See page 39 for coverage of genetic counseling and evaluation, and page 21 for information about prior approval. We now provide Preventive care benefits to screen for diabetes mellitus in adults. Previously, preventive benefits were available for related screening only when performed as part of a metabolic panel. (See page 39.) We now provide Preventive care benefits for Hepatitis C screening in adults. Previously, benefits were not available for this type of screening. (See page 39.) We now provide Preventive care benefits for low-dose CT screenings for lung cancer in adults, ages 55 to 80, with a history of tobacco use. Previously, benefits were not available for this type of screening. (See page 40.) We now limit benefits for tocolytic therapy and related services to those services provided on an inpatient basis. Previously, benefits were also available for in-home services. (See page 45.) Service Benefit Plan 15 Section 2

16 We now provide benefits for the blood and marrow stem cell transplants listed on pages and the clinical trial transplants listed on pages 71-72, when they are performed in a facility with a transplant program that has been accredited by the Foundation for the Accreditation of Cellular Therapy (FACT), a Blue Distinction Center for Transplants, or a Cancer Research Facility. Previously, benefits for these transplants were limited to transplant procedures performed at Blue Distinction Centers for Transplants. (See pages ) We now reimburse you for eligible travel expenses related to covered transplants performed at designated Blue Distinction Centers for Transplants when you live fifty (50) miles or more from the facility, subject to the criteria described on page 74. We now provide benefits for covered organ transplants only when they are performed in facilities with a Medicare-Approved Transplant Program for the type of transplant anticipated, except where Medicare does not maintain an associated approved program. Previously, benefits for organ transplants were not subject to this requirement. (See page 67.) We now provide benefits for implantation of an artificial heart as a bridge to transplant or destination therapy. Previously, benefits were not available for these services. See Section 5(b) for the benefit levels that apply to surgical and anesthesia services. See Section 5(c) for our coverage of inpatient hospital care. Benefits for simultaneous liver-kidney transplants, single lung transplants, double lung transplants, and pancreas transplants that are performed in Blue Distinction Centers for Transplants, are now limited to adult members. Previously, benefits for these types of transplants were not limited to adults. (See page 74.) You now pay a reduced copayment of $150 per admission under Standard Option and $100 per day ($500 maximum) under Basic Option when you use a designated Blue Distinction Center for the inpatient bariatric, hip, knee, or spine surgeries listed on page 84. Regular benefit levels apply to charges for the professional services, including surgery and anesthesia. (See page 84.) You now pay a copayment of $100 per day per facility under Standard Option and $25 per day per facility under Basic Option when you use a facility designated as a Blue Distinction Center for Bariatric Surgery for outpatient laparoscopic gastric banding surgery. Regular benefit levels apply to charges for the professional services, including surgery and anesthesia. (See page 85.) We have clarified how much you pay for emergency room services related to an accidental injury or medical emergency. When services are performed by Non-preferred professional providers in a Preferred hospital, you are responsible for your cost-share for those services, plus any difference between our allowance and the billed amount. (See pages ) We now provide benefits for outpatient facility mental health and substance abuse services when performed and billed by residential treatment centers. (See page 99.) We now provide prescription drug benefits in full for generic medicines (limited to tamoxifen and raloxifene) to reduce breast cancer risk for women, age 35 or over, who have not been diagnosed with any form of breast cancer. Covered medicines must be purchased at Preferred retail pharmacies or, for Standard Option only, through the Mail Service Prescription Drug Program. Previously, your prescription drug coverage did not include these benefits. (See page 107.) You are entitled to receive a $50 health account to be used for qualified medical expenses when you complete a Blue Health Assessment (BHA) questionnaire. Previously, you were entitled to receive a $40 health account when you completed the BHA. [See Section 5(h).] We now use the Local Plan s UCR amount as our Plan allowance for services, drugs, or supplies provided by Non-participating physicians and other covered health care professionals when there is no Medicare participating fee schedule amount or Medicare Part B Drug Average Sale Price (ASP). Previously, our allowance was 60% of the billed charge for services, drugs, or supplies with no Medicare fee schedule amount or ASP. (See page 150.) Service Benefit Plan 16 Section 2

17 Identification cards Where you get covered care Covered professional providers Section 3. How you receive benefits We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You will need it whenever you receive services from a covered provider, or fill a prescription through a Preferred retail pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation letter (for annuitants), or your electronic enrollment system (such as Employee Express) confirmation letter. If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call the Local Plan serving the area where you reside and ask them to assist you, or write to us directly at: FEP Enrollment Services, 840 First Street, NE, Washington, DC You may also request replacement cards through our website, Under Standard Option, you can get care from any covered professional provider or covered facility provider. How much we pay and you pay depends on the type of covered provider you use. If you use our Preferred, Participating, or Member providers, you will pay less. Under Basic Option, you must use those covered professional providers or covered facility providers that are Preferred providers for Basic Option in order to receive benefits. Please refer to page 20 for the exceptions to this requirement. Refer to page 13 for more information about Preferred providers. The term primary care provider includes family practitioners, general practitioners, medical internists, pediatricians, obstetricians/gynecologists, and physician assistants. We provide benefits for the services of covered professional providers, as required by Section 2706(a) of the Public Health Service Act (PHSA). Covered professional providers are health care providers who perform covered services when acting within the scope of their license or certification under applicable state law and who furnish, bill, or are paid for their health care services in the normal course of business. Covered services must be provided in the state in which the provider is licensed or certified. Your Local Plan is responsible for determining the provider s licensing status and scope of practice. As reflected in Section 5, the Plan does limit coverage for some services, in accordance with accepted standards of clinical practice regardless of the geographic area. Under Standard Option, we cover any licensed professional provider for covered services performed within the scope of that license. Under Basic Option, we cover any licensed professional provider who is Preferred for covered services performed within the scope of that license. Covered professional providers include: Physicians Doctors of medicine (M.D.); Doctors of osteopathy (D.O.); Doctors of dental surgery (D.D.S.); Doctors of medical dentistry (D.M.D.); Doctors of podiatric medicine (D.P.M.); Doctors of optometry (O.D.); and Doctors of Chiropractic/chiropractors (D.C.); and Other Covered Health Care Professionals Professionals such as the health care providers listed below and on page 18, when they provide covered services and meet the state s applicable licensing or certification requirements. If the state has no applicable licensing or certification requirement, the provider must meet the requirements of the Local Plan. Audiologist Clinical Psychologist Clinical Social Worker Diabetic Educator Dietician Independent Laboratory Lactation Consultant Mental Health or Substance Abuse professional Service Benefit Plan 17 Section 3

18 Certified Midwife Nurse Practitioner/Clinical Specialist Nursing School Administered Clinic Nutritionist Physical, Speech, and Occupational Therapist Physician Assistant Covered facility providers Covered facilities include those listed below, when they meet the state s applicable licensing or certification requirements. Hospital An institution, or a distinct portion of an institution, that: 1. Primarily provides diagnostic and therapeutic facilities for surgical and medical diagnoses, treatment, and care of injured and sick persons provided or supervised by a staff of licensed doctors of medicine (M.D.) or licensed doctors of osteopathy (D.O.), for compensation from its patients, on an inpatient or outpatient basis; 2. Continuously provides 24-hour-a-day professional registered nursing (R.N.) services; and 3. Is not, other than incidentally, an extended care facility; a nursing home; a place for rest; an institution for exceptional children, the aged, drug addicts, or alcoholics; or a custodial or domiciliary institution having as its primary purpose the furnishing of food, shelter, training, or non-medical personal services. Note: We consider college infirmaries to be Non-member hospitals. In addition, we may, at our discretion, recognize any institution located outside the 50 states and the District of Columbia as a Non-member hospital. Freestanding Ambulatory Facility A freestanding facility, such as an ambulatory surgical center, freestanding surgi-center, freestanding dialysis center, or freestanding ambulatory medical facility, that: 1. Provides services in an outpatient setting; 2. Contains permanent amenities and equipment primarily for the purpose of performing medical, surgical, and/or renal dialysis procedures; 3. Provides treatment performed or supervised by doctors and/or nurses, and may include other professional services performed at the facility; and 4. Is not, other than incidentally, an office or clinic for the private practice of a doctor or other professional. Note: We may, at our discretion, recognize any other similar facilities, such as birthing centers, as freestanding ambulatory facilities. Blue Distinction Centers Certain facilities have been selected to be Blue Distinction Centers for Bariatric Surgery, Cardiac Care, Knee and Hip Replacement, Spine Surgery, and Complex and Rare Cancers. These facilities meet objective quality criteria established with input from expert physician panels, surgeons, and other medical professionals. Blue Distinction Centers offer comprehensive care delivered by multidisciplinary teams with subspecialty training and distinguished clinical expertise. We cover facility costs for specialty care at designated Blue Distinction Centers at Preferred benefit levels, which means that your out-of-pocket expenses for specialty facility services are limited. In addition, we provide enhanced benefits for covered inpatient facility services related to specific bariatric, knee, hip, and spine surgical procedures, when the surgery is performed at a Blue Distinction Center. We also provide enhanced benefits for covered facility services related to outpatient laparoscopic gastric banding surgery, when the surgery is performed at a Blue Distinction Center for Bariatric Surgery. See pages 84 and 85 for more information. Service Benefit Plan 18 Section 3

19 Facility care that is not part of the Blue Distinction Program is reimbursed according to the network status of the facility. In addition, some Blue Distinction Centers may use professional providers who do not participate in our provider network. Non-participating providers have no agreements with us to limit what they can bill you. This is why it s important to always request Preferred providers for your care. For more information, see pages in Section 4, Your costs for covered services, or call your Local Plan at the number listed on the back of your ID card. For listings of Preferred providers in your area, go to and select Provider Directory to use our National Doctor & Hospital Finder. If you are considering covered bariatric surgery, cardiac procedures, knee or hip replacement, spine surgery, or inpatient treatment for a complex or rare cancer, you may want to consider receiving those services at a Blue Distinction Center. To locate a Blue Distinction Center, go to and select Provider Directory to use our National Doctor & Hospital Finder, or call us at the customer service number listed on the back of your ID card. Blue Distinction Centers for Transplants In addition to the Blue Distinction Centers listed above, you have access to Blue Distinction Centers for Transplants. Blue Distinction Centers for Transplants are selected based on their ability to meet defined clinical quality criteria that are unique for each type of transplant. We provide enhanced benefits for covered transplant services performed at these designated centers as described on page 74. Regular benefits (subject to the regular cost-sharing levels for facility and professional services) are paid for pre- and post-transplant services performed in Blue Distinction Centers for Transplants before and after the transplant period. (Regular benefit levels and cost-sharing amounts also apply to services unrelated to a covered transplant.) Cancer Research Facility A facility that is: 1. A National Cooperative Cancer Study Group institution that is funded by the National Cancer Institute (NCI) and has been approved by a Cooperative Group as a blood or marrow stem cell transplant center; 2. An NCI-designated Cancer Center; or 3. An institution that has a peer-reviewed grant funded by the National Cancer Institute (NCI) or National Institutes of Health (NIH) to study allogeneic or autologous blood or marrow stem cell transplants. FACT-Accredited Facility A facility with a transplant program accredited by the Foundation for the Accreditation of Cellular Therapy (FACT). FACT-accredited cellular therapy programs meet rigorous standards. Information regarding FACT transplant programs can be obtained by contacting the transplant coordinator at the customer service number listed on the back of your ID card or by visiting Note: Certain stem cell transplants must be performed at a FACT-accredited facility (see page 72). Other facilities specifically listed in the benefits descriptions in Section 5(c). Service Benefit Plan 19 Section 3

20 What you must do to get covered care Under Standard Option, you can go to any covered provider you want, but in some circumstances, we must approve your care in advance. Under Basic Option, you must use Preferred providers in order to receive benefits, except under the situations listed below. In addition, we must approve certain types of care in advance. Please refer to Section 4, Your costs for covered services, for related benefits information. 1. Medical emergency or accidental injury care in a hospital emergency room and related ambulance transport as described in Section 5(d), Emergency services/accidents; 2. Professional care provided at Preferred facilities by Non-preferred radiologists, anesthesiologists, certified registered nurse anesthetists (CRNAs), pathologists, emergency room physicians, and assistant surgeons; 3. Laboratory and pathology services, X-rays, and diagnostic tests billed by Non-preferred laboratories, radiologists, and outpatient facilities; 4. Services of assistant surgeons; 5. Care received outside the United States, Puerto Rico, and the U.S. Virgin Islands; or 6. Special provider access situations, other than those described above. We encourage you to contact your Local Plan for more information in these types of situations before you receive services from a Non-preferred provider. Unless otherwise noted in Section 5, when services are covered under Basic Option exceptions for Non-preferred provider care, you are responsible for the applicable coinsurance or copayment, and may also be responsible for any difference between our allowance and the billed amount. Transitional care Specialty care: If you have a chronic or disabling condition and lose access to your specialist because we drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB plan, or lose access to your Preferred specialist because we terminate our contract with your specialist for reasons other than for cause, you may be able to continue seeing your specialist and receiving any Preferred benefits for up to 90 days after you receive notice of the change. Contact us or, if we drop out of the Program, contact your new plan. If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist and your Preferred benefits will continue until the end of your postpartum care, even if it is beyond the 90 days. If you are hospitalized when your enrollment begins We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call us immediately. If you have not yet received your Service Benefit Plan ID card, you can contact your Local Plan at the telephone number listed in your local telephone directory. If you already have your new Service Benefit Plan ID card, call us at the number on the back of the card. If you are new to the FEHB Program, we will reimburse you for your covered services while you are in the hospital beginning on the effective date of your coverage. However, if you changed from another FEHB plan to us, your former plan will pay for the hospital stay until: you are discharged, not merely moved to an alternative care center; the day your benefits from your former plan run out; or the 92nd day after you become a member of this Plan, whichever happens first. These provisions apply only to the benefits of the hospitalized person. If your plan terminates participation in the FEHB in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such cases, the hospitalized family member s benefits under the new plan begin on the effective date of enrollment. Service Benefit Plan 20 Section 3